In 2012, Yeovil District Hospital NHS Foundation Trust started to build stronger partnerships with local primary care providers to support practices and improve joint working between GPs and hospital services. It expanded the partnership to include commissioners and the council as well as community and mental health services. In 2015, it established a first ‘Symphony care hub’ with care co-ordinators and multidisciplinary teams for people with three or more long-term conditions. It also established an enhanced primary care model that sees additional roles, in particular health coaches, introduced into practice teams.

In 2015, commissioners and providers gained vanguard funding to develop the model. Commissioners are planning to contract with a single provider or partnership to hold a single budget for the population and deliver a range of primary care, community health, mental health and hospital services. The intention is to move over time to cover almost the entire health and care budget.

In South Somerset, commissioners and providers envisage that Yeovil District Hospital, primary care, and potentially other providers will establish a corporate joint venture to hold the budget and deliver services. However, they are currently exploring whether this would create additional VAT liabilities and other issues. An alternative may be for a foundation trust to hold the budget and act as a lead provider, working in partnership with primary care providers. Commissioners are working on similar approaches for the rest of the county with the aim of establishing a county-wide accountable care organisation by 2019.

Interviewees envisaged that providers might enter the joint venture on different terms – some as full partners sharing risk and reward, some with a gain-share agreement and some as consultative partners. This would allow a broad range of providers to share in decision-making, even if they were unable to invest or bear risk. The intention is that the lead entity will sub-contract with other organisations, including the parent companies, to deliver different services in the new system. This means they will not need to transfer staff and services into the joint venture.

At the same time, primary, community and hospital providers have continued to re-organise services. This has included introducing new primary care services and developing three new ‘Complex care hubs’ for people with complex needs.

Yeovil District Hospital has played a lead role in bringing together primary care practitioners so that they can participate in the new system. In April 2016, it established a subsidiary, Symphony Healthcare Services, to enable primary care practices to integrate into a larger organisation. GPs can now become salaried employees with access to shared services. All the GP practices in Somerset have also joined a limited company, Somerset Primary Healthcare, as a basis for working with other providers to improve the system.

Somerset CCG has launched a process to enable one or more provider entities across Somerset to hold a budget and oversee the system. It envisages entering a 5- to 10-year, outcomes-based contract.

The original intention was to include social care funding within the contract. However, the current plan is to consider how best to bring social care services into the new system at a later phase.

Finally, the CCG envisages restructuring its services so that it can play a more strategic role in overseeing the system. It expects a ‘managed services organisation’ will sit within the accountable care organisation and act as its ‘engine room’.